Inspection Reports for
Veterans Community Living Center at Fitzsimons
CO, 80045
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
17.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
240% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 21, 2024
Visit Reason
The inspection was conducted due to allegations of resident-to-resident physical and sexual abuse involving multiple residents, including incidents on 5/29/24, 9/16/24, and 11/17/24.
Complaint Details
The complaint investigation substantiated physical abuse between Residents #60 and #127 on 11/17/24 and sexual abuse by Resident #92 against Resident #45 on 5/29/24 and 9/16/24. The facility's internal investigations included interviews, record reviews, and staff statements. The sexual abuse was substantiated, but no documentation was found regarding substantiation status for the physical abuse. The facility implemented 15-minute checks and moved Resident #92 to a different unit after the incidents.
Findings
The facility failed to prevent resident-to-resident physical and sexual abuse involving four residents out of five reviewed. The investigation substantiated physical abuse between Residents #60 and #127 and sexual abuse by Resident #92 against Resident #45 on two occasions. The facility lacked timely and effective interventions to protect residents at risk and failed to update assessments after cognitive decline was noted.
Deficiencies (4)
Failed to prevent resident-to-resident physical abuse between Resident #127 and Resident #60, who had a known history of aggressive behaviors.
Failed to have timely effective interventions to protect Resident #127 from physical aggression and wandering into other residents' rooms.
Failed to prevent resident-to-resident sexual abuse of Resident #45 by Resident #92 on 5/29/24 and 9/16/24.
Failed to complete an updated assessment for Resident #92 after noted cognitive decline due to dementia.
Report Facts
Residents reviewed for abuse: 45
Residents affected: 4
Frequency of behavior monitoring: 15
Dates of sexual abuse incidents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA | Nursing Home Administrator | Provided facility policy, interviewed regarding incidents and facility response |
| CNA #6 | Certified Nurse Aide | Interviewed about resident interactions and altercation on 11/17/24 |
| LPN #1 | Licensed Practical Nurse | Interviewed about resident behaviors and interventions |
| SSD | Social Services Director | Interviewed regarding sexual abuse incidents and resident interactions |
| SSA | Social Services Assistant | Interviewed regarding sexual abuse incidents and resident interactions |
| DSW | Divisional Social Worker | Interviewed about resident relationships and cognitive status |
Inspection Report
Routine
Deficiencies: 8
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, abuse prevention, care planning, dental care, infection control, and other standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, prevent resident-to-resident abuse and sexual abuse, revise comprehensive care plans timely, provide appropriate wound care and skin treatment, assist residents with dental care needs, accommodate resident food preferences, provide appropriate range of motion treatments, and maintain an effective infection prevention and control program including water management and proper wound care instrument sanitation.
Deficiencies (8)
Failed to ensure call light was within reach for Resident #65 with limited range of motion, impacting dignity and timely assistance.
Failed to prevent resident-to-resident physical and sexual abuse involving Residents #127, #60, #45, and #92, including inadequate interventions and monitoring.
Failed to revise and review comprehensive care plans for five residents (#122, #104, #81, #46, #65) to reflect medication use and skin treatment.
Failed to ensure timely reporting and appropriate treatment of new skin alterations for Resident #65, including delayed notification and incomplete care plan updates.
Failed to provide appropriate range of motion treatment for Resident #45, including failure to follow physician's order for exercise bike use.
Failed to assist residents (#81, #45, #93) in obtaining timely routine or emergency dental care, including failure to schedule dental appointments and follow up on dental pain complaints.
Failed to provide food that accommodated Resident #10's preferences, including failure to offer Mexican food and hot sauce as documented in care plan and meal ticket.
Failed to maintain an infection prevention and control program, including inadequate water management program lacking detailed building water system description and monitoring, and improper sanitation of wound care scissors.
Report Facts
Residents reviewed: 45
Residents affected by dignity deficiency: 1
Residents affected by abuse deficiency: 4
Residents with care plan deficiencies: 5
Residents with dental care deficiencies: 3
Residents with food preference deficiency: 1
Residents with wound care deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding call light placement for Resident #65 and wound care practices |
| CNA #1 | Certified Nurse Aide | Interviewed regarding call light placement responsibilities |
| CNA #2 | Certified Nurse Aide | Interviewed regarding call light placement and skin condition reporting for Resident #65 |
| Assistant Director of Nursing | ADON | Interviewed regarding call light policies, care plan responsibilities, and skin care monitoring |
| Unit Manager | UM | Interviewed regarding wound care responsibilities and infection control practices |
| Social Services Director | SSD | Interviewed regarding abuse investigations, dental care scheduling, and resident interactions |
| Social Services Assistant | SSA | Interviewed regarding abuse investigations and dental care scheduling |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding resident aggression and monitoring |
| Certified Nurse Aide #6 | CNA | Interviewed regarding resident interactions and monitoring |
| Nursing Home Administrator | NHA | Interviewed regarding abuse investigations, legionella policy, and resident safety |
| Physical Therapist | PT | Interviewed regarding exercise bike use and resident therapy plans |
| Restorative Manager | RM | Interviewed regarding therapy programs and resident participation |
| Registered Dietitian | RD | Interviewed regarding resident nutritional risk and food preferences |
| Dietary Manager | DM | Interviewed regarding meal preparation and resident food preferences |
| RN #1 | Registered Nurse | Interviewed regarding wound care and skin assessments |
| RN #2 | Registered Nurse | Observed and interviewed regarding wound care and instrument sanitation |
| SW #1 | Social Worker | Interviewed regarding dental care scheduling and resident pain |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to investigate allegations of resident-to-resident physical and sexual abuse at the Veterans Community Living Center at Fitzsimons.
Complaint Details
The complaint investigation substantiated physical abuse between Resident #60 and Resident #127 on 11/17/24 and sexual abuse by Resident #92 of Resident #45 on 5/29/24 and 9/16/24. The sexual abuse was substantiated, and multiple investigations and interviews were conducted. The facility implemented 15-minute checks and moved Resident #92 to a different unit after the incidents.
Findings
The facility failed to prevent resident-to-resident physical and sexual abuse involving multiple residents. Investigations substantiated physical abuse between Residents #60 and #127 and sexual abuse by Resident #92 against Resident #45 on two occasions. The facility lacked timely and effective interventions to protect residents at risk.
Deficiencies (1)
F 0600: The facility failed to protect residents from physical and sexual abuse by other residents, including failure to prevent physical altercations between Residents #60 and #127 and sexual abuse by Resident #92 of Resident #45 on 5/29/24 and 9/16/24.
Report Facts
Residents reviewed for abuse: 45
Residents affected: 4
Behavior monitoring frequency: 15
Dates of sexual abuse incidents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA | Nursing Home Administrator | Interviewed regarding physical altercation and abuse investigations |
| Director of Nursing | Director of Nursing | Notified of physical altercation and involved in investigation |
| Certified Nurse Aide #6 | Certified Nurse Aide | Interviewed about resident interactions and altercation |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about resident behaviors and interventions |
| Social Services Director | Social Services Director | Interviewed regarding sexual abuse incidents and resident behaviors |
| Social Services Assistant | Social Services Assistant | Interviewed regarding sexual abuse incidents and resident behaviors |
| Deputy Director | Deputy Director | Interviewed regarding sexual abuse incidents |
| Activities Director | Activities Director | Observed sexual abuse incident on 9/16/24 |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Nov 21, 2024
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident dignity, abuse, care plan deficiencies, wound care, dental care, infection control, and other regulatory compliance issues at the Veterans Community Living Center at Fitzsimons.
Complaint Details
The investigation substantiated multiple complaints including failure to maintain resident dignity, prevent abuse, provide adequate care planning, wound care, dental services, food preferences, and infection control.
Findings
The facility failed to ensure resident dignity and respect, prevent resident-to-resident physical and sexual abuse, maintain and revise comprehensive care plans, provide appropriate wound care and dental services, accommodate resident food preferences, and maintain an effective infection prevention and control program including a water management program and proper wound care instrument sanitation.
Deficiencies (8)
F 0550: The facility failed to promote and maintain Resident #65's dignity by not ensuring his call light was within reach despite his limited range of motion.
F 0600: The facility failed to prevent resident-to-resident physical abuse between Residents #127 and #60, failed to protect Resident #127 from aggression, and failed to prevent sexual abuse of Resident #45 by Resident #92 on two occasions.
F 0657: The facility failed to revise and review comprehensive care plans for five residents to reflect medication use and skin treatment interventions.
F 0684: The facility failed to provide treatment and care according to orders for Resident #65's skin condition, including timely reporting of new skin alterations by CNAs.
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion for Resident #45, including failure to follow physician's order for exercise bike use.
F 0790: The facility failed to provide routine and emergency dental care for Residents #81, #45, and #93, including failure to schedule timely dental appointments and address dental pain and broken dentures.
F 0806: The facility failed to provide food that accommodated Resident #10's preferences, including failure to offer Mexican food and hot sauce as documented in the care plan and meal ticket.
F 0880: The facility failed to maintain an infection prevention and control program by not having a comprehensive water management program describing building water systems and monitoring points, and failed to properly sanitize wound care scissors after use.
Report Facts
Residents reviewed: 45
Residents affected by dignity deficiency: 1
Residents affected by abuse deficiency: 4
Residents with care plan deficiencies: 5
Residents with wound care deficiency: 1
Residents with ROM deficiency: 1
Residents with dental care deficiency: 3
Residents with food preference deficiency: 1
Residents affected by infection control deficiency: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in wound care and infection control deficiency regarding improper sanitation of scissors |
| UM | Unit Manager | Named in wound care and infection control deficiencies regarding wound care oversight and education |
| ADON | Assistant Director of Nursing | Named in care plan and wound care deficiencies |
| SSD | Social Services Director | Named in abuse, dental care, and care plan deficiencies |
| SSA | Social Services Assistant | Named in abuse and dental care deficiencies |
| RN #1 | Registered Nurse | Named in wound care deficiency |
| CNA #2 | Certified Nurse Aide | Named in wound care deficiency |
| PT | Physical Therapist | Named in ROM deficiency |
| RM | Restorative Manager | Named in ROM deficiency |
| RD | Registered Dietitian | Named in food preference deficiency |
| DM | Dietary Manager | Named in food preference deficiency |
| SW #1 | Social Worker | Named in dental care deficiency |
| NHA | Nursing Home Administrator | Named in infection control deficiency |
| FDM | Facility Director of Maintenance | Named in infection control deficiency |
| DD | Deputy Director | Named in infection control deficiency |
Inspection Report
Deficiencies: 7
Date: Jun 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, trauma-informed care, hydration, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate care for residents with limited range of motion, failure to prevent elopement of a high-risk resident, failure to provide trauma-informed care for residents with PTSD, failure to prevent unnecessary medication use including excessive acetaminophen dosing and antidepressant use without proper assessment and consent, failure to ensure adequate hydration for a resident, and failure to implement effective quality assurance and performance improvement processes.
Deficiencies (7)
Failure to provide appropriate care for Resident #28 with limited range of motion and bilateral hand contractures.
Failure to ensure Resident #106, at high risk of elopement, was kept safe leading to two elopement incidents.
Failure to provide trauma-informed care and conduct trauma assessments for eight residents with PTSD or trauma history.
Failure to prevent excessive acetaminophen dosing for Resident #83 exceeding recommended daily limits.
Failure to assess Resident #58 for depression prior to ordering and administering antidepressant medication at family request without resident consent.
Failure to ensure Resident #90 was offered sufficient hydration and water pitchers were kept within reach.
Failure of the quality assurance performance improvement (QAPI) program to identify and address elopement risks and security failures leading to immediate jeopardy.
Report Facts
Residents sampled: 53
Acetaminophen daily dose: 3575
Acetaminophen excess dose: 575
Resident #90 hydration deficit: 450
Resident #90 hydration deficit: 120
PHQ-9 depression score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Noted excessive acetaminophen dosing for Resident #83 and planned to notify physician |
| RPH | Registered Pharmacist | Confirmed excessive acetaminophen dosing for Resident #83 |
| NHA | Nursing Home Administrator | Discussed failures in elopement prevention and QAPI committee deficiencies |
| DON | Director of Nursing | Interviewed regarding elopement, hydration, and antidepressant medication consent and assessment |
| SSD | Social Services Director | Discussed lack of trauma assessments and antidepressant medication consent issues |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 28, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident care, safety, medication management, hydration, trauma-informed care, and quality assurance at the Veterans Community Living Center at Fitzsimons.
Complaint Details
The complaint investigation focused on multiple issues including failure to provide appropriate care for residents with limited range of motion, failure to prevent elopement of a high-risk resident, failure to provide trauma-informed care, medication management concerns including excessive acetaminophen dosing and antidepressant use without assessment or consent, inadequate hydration, and ineffective quality assurance processes. Immediate jeopardy was identified related to Resident #106's elopements.
Findings
The facility failed to provide appropriate care for residents with limited range of motion, failed to prevent elopement of a high-risk resident, failed to provide trauma-informed care for residents with PTSD, administered excessive acetaminophen doses to a resident, failed to assess and obtain consent for antidepressant use, failed to ensure adequate hydration for a resident, and failed to maintain an effective quality assurance program addressing these issues.
Deficiencies (7)
F0688: The facility failed to provide appropriate care to maintain or improve range of motion for Resident #28, specifically failing to implement preventative measures for bilateral hand contractures.
F0689: The facility failed to ensure Resident #106, diagnosed with dementia and at high risk for elopement, was kept safe, resulting in two successful elopements due to wanderguard system failures and inadequate staff supervision.
F0699: The facility failed to provide trauma-informed and culturally competent care for eight residents with PTSD, lacking trauma assessments, identification of triggers, and individualized care plans.
F0757: Resident #83 received an excessive daily dose of acetaminophen totaling 3575 mg, exceeding the recommended maximum of 3000 mg.
F0758: Resident #58 was prescribed and administered an antidepressant without documented assessment for depression or resident consent, initiated at the request of the resident's family.
F0807: Resident #90 was not offered sufficient fluids throughout the day, and the water pitcher was not kept within reach, risking dehydration.
F0867: The facility's Quality Assurance Performance Improvement (QAPI) program failed to identify and address elopement risks and security failures related to Resident #106's multiple elopements.
Report Facts
Resident sample size: 53
Resident #28 range of motion: 1
Resident #106 elopements: 2
Resident #83 acetaminophen dose: 3575
Resident #58 PHQ-9 score: 0
Resident #90 fluid intake: 630
Resident #90 fluid intake: 960
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Noted excessive acetaminophen dosing for Resident #83 and planned to notify physician. |
| RPH | Registered Pharmacist | Confirmed excessive acetaminophen dosing for Resident #83. |
| NHA | Nursing Home Administrator | Discussed failures in security guard education and QAPI committee regarding Resident #106 elopements. |
| DON | Director of Nursing | Interviewed regarding hydration practices and antidepressant consent and assessment. |
| SSD | Social Services Director | Interviewed about antidepressant medication initiation without resident assessment or consent. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 27, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding resident abuse, failure to provide CPR as ordered, inadequate dementia care, failure to assess and notify physician of change in condition, and failure to maintain an effective quality assurance program.
Complaint Details
The complaint investigation revealed substantiated findings of resident to resident abuse, failure to provide CPR as ordered for two residents who died, failure to assess and notify physician of change in condition for one resident, inadequate dementia care for two residents, failure to update facility assessment, and failure to maintain an effective quality assurance program.
Findings
The facility failed to protect residents from abuse and neglect, failed to provide CPR as ordered for residents in cardiac arrest, failed to assess and notify physicians of changes in resident conditions, failed to provide adequate dementia care and activities, and failed to maintain an effective quality assurance program. Multiple residents were involved in altercations, and staff failed to provide required supervision and interventions. The facility also failed to update its comprehensive facility assessment and to conduct effective quality assurance activities.
Deficiencies (6)
Failure to protect residents from abuse and neglect, including resident to resident physical altercations and inadequate supervision.
Failure to provide basic life support including CPR to residents with orders for resuscitation, resulting in immediate jeopardy.
Failure to assess and notify physician of change in condition for a resident with irregular vital signs.
Failure to provide appropriate dementia care including person-centered care plans, interventions, and meaningful activities.
Failure to conduct and document a comprehensive facility-wide assessment to determine resources necessary to care for residents competently.
Failure to maintain an effective quality assurance and performance improvement program to identify and address facility compliance concerns.
Report Facts
Residents reviewed for abuse: 17
Residents on secured unit: 14
One-to-one monitoring start date: Resident #1 placed on one-to-one monitoring on 12/21/22.
BIMS score Resident #1: 4
BIMS score Resident #2: 3
Blood pressure Resident #3: 171
Pulse Resident #3: 90
Respirations Resident #3: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in failure to provide CPR to Resident #3. |
| RN #2 | Registered Nurse Supervisor | Named in failure to provide CPR to Residents #3 and #4. |
| LPN #3 | Licensed Practical Nurse | Named in failure to provide CPR to Resident #4. |
| Social Services Director | Conducted investigation into resident altercation and abuse. | |
| Director of Clinical Operations | Provided facility policies and interviewed regarding supervision and CPR. | |
| Nursing Home Administrator | Interviewed regarding facility assessment, QAPI, and corrective actions. | |
| Activities Director #1 | Interviewed regarding activities for residents with dementia. | |
| AA #2 | Interviewed regarding secured unit activities and resident preferences. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 27, 2023
Visit Reason
The inspection was conducted following complaints and allegations regarding resident abuse, failure to provide CPR as ordered, inadequate dementia care, failure to assess and notify physician of change in condition, and lack of effective quality assurance.
Complaint Details
The complaint investigation revealed multiple failures including resident abuse, failure to provide CPR as ordered for two residents who died, failure to assess and notify physician of change of condition, inadequate dementia care, and ineffective quality assurance program.
Findings
The facility failed to prevent resident-to-resident abuse, failed to provide CPR as ordered for two residents who died, failed to assess and notify the physician of a resident's change of condition, failed to provide adequate dementia care and activities, and failed to maintain an effective quality assurance program.
Deficiencies (6)
F0600: The facility failed to protect residents from abuse and neglect, resulting in actual harm to two residents involved in a physical altercation.
F0678: The facility failed to provide basic life support, including CPR, to two residents with orders for CPR, resulting in immediate jeopardy to resident health or safety.
F0684: The facility failed to assess and notify the physician of a resident's change of condition after irregular vital signs were noted, resulting in minimal harm or potential for actual harm.
F0744: The facility failed to provide appropriate dementia care and person-centered activities for two residents, resulting in minimal harm or potential for actual harm.
F0838: The facility failed to conduct and document a comprehensive facility-wide assessment to determine resources necessary to care for residents competently during day-to-day operations and emergencies.
F0867: The facility failed to implement an effective quality assurance program to identify and address compliance concerns, including failure to provide CPR as ordered.
Report Facts
Residents reviewed for abuse: 17
Residents reviewed for CPR orders: 3
Residents on secured dementia unit: 14
BIMS score Resident #1: 4
BIMS score Resident #2: 3
BIMS score Resident #3: 6
BIMS score Resident #4: 13
Resident #3 blood pressure: 171
Resident #3 pulse: 90
Resident #3 respirations: 22
One-to-one monitoring start date Resident #1: 2022
Resident #2 prior altercations: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in failure to provide CPR to Resident #3. |
| RN #2 | Registered Nurse Supervisor | Named in failure to provide CPR to Residents #3 and #4. |
| LPN #1 | Licensed Practical Nurse | Named in failure to provide CPR to Resident #3. |
| LPN #3 | Licensed Practical Nurse | Named in failure to provide CPR to Resident #4. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding one-to-one supervision of Resident #1. |
| CNA #2 | Certified Nurse Aide | Interviewed regarding training and resident redirection. |
| Activities Director #1 | Activities Director | Interviewed regarding activities for residents with dementia. |
| NHA | Nursing Home Administrator | Interviewed regarding facility assessment and QAPI program. |
| DCO | Director of Clinical Operations | Interviewed regarding dementia care and CPR policy. |
| SSD | Social Services Director | Interviewed regarding resident altercation investigation. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 20, 2020
Visit Reason
The inspection was conducted based on complaints regarding resident care, including the use of restraints for discipline or convenience, failure to provide appropriate activities for residents with dementia, and inadequate communication and coordination of dialysis care.
Complaint Details
The complaint investigation focused on allegations that the facility used restraint for discipline by removing a resident's powered wheelchair, failed to provide appropriate activities for a resident with dementia, and did not maintain proper communication with the dialysis center for a resident receiving dialysis.
Findings
The facility failed to prevent the use of restraint as discipline by taking away Resident #70's powered wheelchair, causing emotional harm. It also failed to provide person-centered activities for Resident #88 with advanced dementia, and failed to establish proper communication and agreements with the dialysis center for Resident #106, resulting in incomplete dialysis communication forms and lack of coordination.
Deficiencies (3)
Failed to prevent use of restraint for discipline by taking Resident #70's powered wheelchair away, causing humiliation and depression.
Failed to provide person-centered activities that met the interests and needs of Resident #88 with advanced dementia.
Failed to establish and maintain communication and agreement with dialysis center for Resident #106, resulting in incomplete dialysis communication forms and lack of coordination.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #11 | Restorative Nurse | Interviewed regarding PPV use and disciplinary removal of powered wheelchair |
| Social Services Director | Social Services Director | Interviewed regarding PPV policy and resident mobility |
| Director of Physical Therapy | Director of Physical Therapy | Interviewed regarding PPV assessment and safety |
| MDS Coordinator | MDS Coordinator | Interviewed regarding resident behavior and PPV removal |
| CNA #5 | Certified Nurse Aide | Interviewed regarding activities provided to Resident #88 |
| CNA #2 | Certified Nurse Aide | Interviewed regarding Resident #88's participation in activities |
| RTA #4 | Recreational Therapy Aide | Interviewed regarding activities programming and Resident #88 |
| Recreational Therapy Director | Recreational Therapy Director | Interviewed regarding Resident #88's activity needs |
| RTA #5 | Recreational Therapy Aide | Interviewed regarding sensory activities for Resident #88 |
| DON | Director of Nursing | Interviewed regarding activities and dialysis communication |
| NHA | Nursing Home Administrator | Interviewed regarding dialysis agreement and communication |
| RN #9 | Registered Nurse | Interviewed regarding dialysis communication form completion |
| RN #3 | Registered Nurse | Interviewed regarding dialysis communication form responsibilities |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding dialysis communication form and resident care |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding dialysis communication form completion |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding dialysis communication form and follow-up |
Inspection Report
Routine
Deficiencies: 3
Date: Jan 20, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, activities, and dialysis services at the Veterans Community Living Center at Fitzsimons.
Findings
The facility was found deficient in protecting residents from restraint used for discipline, providing person-centered activities for residents with dementia, and ensuring proper communication and agreements with an outside dialysis center for a resident receiving dialysis services.
Deficiencies (3)
F 0600: The facility failed to prevent the use of restraint for discipline by taking Resident #70's personal powered vehicle away, causing humiliation and depression.
F 0679: The facility failed to provide person-centered activities that met the interests and needs of Resident #88 with advanced dementia, resulting in lack of appropriate stimulation and engagement.
F 0698: The facility failed to establish a signed agreement with the dialysis center prior to Resident #106 receiving dialysis and failed to ensure complete communication forms documenting dialysis care.
Report Facts
Residents reviewed for activities: 12
Residents reviewed for dialysis: 4
Dialysis communication forms reviewed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #11 | Restorative Nurse | Interviewed regarding PPV use and disciplinary removal |
| Social Services Director | Social Services Director | Interviewed regarding Resident #70's PPV use and policy |
| Director of Physical Therapy | Director of Physical Therapy | Interviewed regarding PPV assessments |
| MDS Coordinator | MDS Coordinator | Interviewed regarding Resident #70's PPV removal |
| CNA #5 | Certified Nurse Aide | Interviewed regarding activities offered to Resident #88 |
| CNA #2 | Certified Nurse Aide | Interviewed regarding Resident #88's activity participation |
| RTA #4 | Recreational Therapy Aide | Interviewed regarding activities programming |
| Recreational Therapy Director | Recreational Therapy Director | Interviewed regarding Resident #88's activity needs |
| RTA #3 | Recreational Therapy Aide | Interviewed regarding Resident #88's activity needs |
| RTA #5 | Recreational Therapy Aide | Interviewed regarding sensory activities for Resident #88 |
| Director of Nursing | Director of Nursing | Interviewed regarding activities and dialysis communication |
| Registered Nurse #9 | Registered Nurse | Interviewed regarding dialysis communication forms |
| Registered Nurse #3 | Registered Nurse | Interviewed regarding dialysis communication forms |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding dialysis communication forms |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding dialysis communication forms |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding dialysis communication forms |
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